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KROGER PHARMACY #409
DSH180043 AdventHealth Manchester
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Covered Entity Details
Entity Name
AdventHealth Manchester
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180043
Entity Address
210 MARIE LANGDON DRIVE
MANCHESTER, KY 40962
Medicare Provider Number
180043
Participating Start Date
10/1/2017
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #409
Pharmacy Address
1732 WEST HWY 192
LONDON, KY 40741
Pharmacy Comments
Contract Details
Approval Date
7/17/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/19/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jesse Kleven, VP/CFO AdventHealth Manchester
(606) 598-1035
Contract Pharmacy Representative
Kroger Health
Eva Brumfield, Strategic Program Director
(651) 357-2109
Signed By Date
7/17/2023
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